Provider Demographics
NPI:1497870927
Name:MARY LEE DEPUGH NURSING HOME ASSOCIATION, INC
Entity Type:Organization
Organization Name:MARY LEE DEPUGH NURSING HOME ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHOVER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:407-644-6634
Mailing Address - Street 1:550 W MORSE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4206
Mailing Address - Country:US
Mailing Address - Phone:407-644-6634
Mailing Address - Fax:407-645-2520
Practice Address - Street 1:550 W MORSE BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4206
Practice Address - Country:US
Practice Address - Phone:407-644-6634
Practice Address - Fax:407-645-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1324096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020158800Medicaid
FL020158800Medicaid